Digital Innovation and Integrated Care in People With Diabetes in Western Sydney: Retrospective Cohort Study.

IF 2.9 Q2 Medicine

JMIR Diabetes Pub Date : 2025-09-11 DOI:10.2196/64832

Ummul Mahfuza, Gideon Meyerowitz-Katz, Riham Abdulla Rasheed, Helen Dick, Glen Maberly, Rajini Jayaballa

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Abstract

Background: The COVID-19 pandemic catalyzed the adoption of digital technologies in health care. This study assesses a digital-first integrated care model for type 2 diabetes management in Western Sydney, using continuous glucose monitoring (CGM) and virtual Diabetes Case Conferences (DCC) involving the patient, general practitioner (GP), diabetes specialist, and diabetes educator at the same time.

Objective: This study aims to assess the effectiveness of the innovative diabetes clinics in Western Sydney.

Methods: In 2020, a total of 833 new patients with type 2 diabetes were seen at Western Sydney Diabetes (WSD) clinics. An early cohort of 103 patients was evaluated before and after participation in virtual DCC, incorporating CGM data analysis, digital educational resources, and remote consultations with a diabetes multidisciplinary team. Assessments were conducted at baseline and 3-4 months post DCC.

Results: The integration of CGM and virtual consultations significantly improved glycemic control. Hemoglobin A_1c (HbA_1c) levels decreased notably from 9.6% to 8.2% (average reduction of 1.4%; 95% CI 1.03-1.82; P<.001). Time in range (TIR) as measured by CGM increased substantially from 46% to 73% (95% CI 20-32; P<.001), and the glucose management indicator (GMI) improved from 7.9% to 7% (average reduction of 0.9%; 95% CI 0.55-1.2; P<.001). Despite no significant change in the total daily insulin dose, the proportion of patients on insulin therapy rose from 27% to 39% (P<.001), indicating more targeted and effective diabetes management.

Conclusions: Our findings demonstrate the effectiveness of a digitally enabled integrated care model in managing type 2 diabetes. The use of CGM technology, complemented by virtual DCCs and digital educational tools, not only facilitated better disease management and patient engagement but also empowered primary care providers with advanced management capabilities. This digital approach addresses traditional barriers in diabetes care, highlighting the potential for scalable, technology-driven solutions in chronic disease management.

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西悉尼地区糖尿病患者的数字创新和综合护理：回顾性队列研究。

背景：2019冠状病毒病大流行促进了数字技术在卫生保健领域的应用。本研究评估了西悉尼2型糖尿病管理的数字优先综合护理模式，使用连续血糖监测（CGM）和虚拟糖尿病病例会议（DCC），涉及患者，全科医生（GP），糖尿病专家和糖尿病教育者。目的：本研究旨在评估西悉尼创新糖尿病诊所的有效性。方法：2020年，西悉尼糖尿病（WSD）诊所共收治了833例新发2型糖尿病患者。在参与虚拟DCC之前和之后，对103名早期队列患者进行了评估，包括CGM数据分析、数字教育资源和糖尿病多学科团队的远程咨询。在基线和DCC后3-4个月进行评估。结果：CGM与虚拟会诊相结合可显著改善血糖控制。血红蛋白A1c （HbA1c）水平从9.6%显著下降到8.2%（平均下降1.4%;95% CI 1.03-1.82）。结论：我们的研究结果证明了数字化综合护理模式在管理2型糖尿病方面的有效性。使用CGM技术，辅以虚拟dcs和数字教育工具，不仅促进了更好的疾病管理和患者参与，而且还赋予初级保健提供者先进的管理能力。这种数字化方法解决了糖尿病护理中的传统障碍，突出了慢性病管理中可扩展的、技术驱动的解决方案的潜力。

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